Best practice principles for inclusive care of transgender and non-binary patients

To be transgender is to have a difference between one’s sex registered at birth and gender identity, clinically known as gender incongruence^​1​. A person’s sex registered at birth is primarily based upon physical factors, such as genitalia, but can also include other biological aspects, including chromosomes and hormones^​2​. Gender identity refers to the way people identify themselves within society’s view of norms, behaviours and relationships that are commonly associated with masculine and feminine traits.

Non-binary people may identify their gender outside of the male/female dichotomy and experience gender incongruence to varying degrees^​2​.

The NHS does not routinely monitor trans status on patient records. According to the 2021 Census of England and Wales, around 300,000 respondents identified themselves as transgender, equating to 0.5% of the population^​3​. By comparison, 0.8% of respondents to the 2023 NHS General Practice Patient Survey reported trans status and, in the same year, in the same survey, a further 0.37% of people identified their gender as non-binary^​4​.

Transgender and non-binary patients face both interpersonal and systemic barriers to equitable health. Transgender health is not taught in core medical curricula, leaving some healthcare professionals feeling uninformed and limited in their capacity to support patients^​5​. 

Data show that transgender patients are more likely to have HIV (transgender men versus cisgender men OR 2.4, 95% CI: 1.43-4.02; transgender men vs cisgender women, OR 4.41, 95% CI: 2.60-7.45; transgender women vs cisgender men OR 3.29, 95% CI: 2.20-4.91; transgender women vs cisgender women OR 6.02 95% CI: 3.98-9.12), hepatitis B (transgender women vs cisgender men OR 1.48, 95% CI: 0.87-2.50; transgender women vs cisgender women OR 1.78, 95% CI: 1.05-3.01) and hepatitis C (transgender men vs cisgender women, OR 2.21, 95% CI: 1.25-3.91; transgender women vs cisgender men OR 1.71, 95% CI: 1.11-2.63; transgender women vs cisgender women OR 3.1, 95% CI: 2.00-4.82) infection^​6​.

Transgender men have been shown to have similar rates of human papillomavirus (HPV)  prevalence to cisgender women, which may not increase risk but does stress the importance of addressing barriers to screening for this community^​7​. 

Gender-affirming hormonal therapies can also modulate risk for breast and prostate cancer risk^​8​. Despite these risk factors, limited education is currently provided for healthcare professionals.

Even when a patient is supported by their healthcare provider, medical systems themselves can be exclusionary. On GP patient records, there is only one marker for sex and gender, despite these being different factors. If a patient re-registers their sex marker to their current gender, their new electronic patient record may:

• Exclude them from relevant screening invitations;
• Close pathways to routine screening;
• Prevent relevant blood tests or referrals being raised;
• Lead to samples being disposed of if they are assumed to be labelled incorrectly;
• Block referral on to appropriate pathways. 

The 2021 Trans Lives Survey — conducted by TransActual, a trans-led organisation that advocates for trans people across the UK — revealed that 70% (n=405) of transgender people reported being impacted by transphobia when accessing general healthcare services. More than half of transgender respondents (57%; n=330) avoided going to the doctor when unwell, while 29% (n=29) have been refused care from gender or sex-specific NHS services because they are transgender^​9​. 

This article will outline how pharmacists can best contribute to the care of transgender and non-binary patients, including necessary communication skills and additional considerations for medicines use to ensure equitable care of this patient group. 

Principles for inclusive communication and patient consultation skills 

To support positive and inclusive consultations under the pressure of limited time and a busy clinical environment, OUTpatients and British Oncology Pharmacy Association (BOPA) developed the TRANScribing online resource, which can be viewed here^​10​. To use this resource most effectively, it is recommended to be cognisant of the following: 

1. Use inclusive language

Appropriate language is vital in maintaining rapport. This includes being sensitive to the individual choices of the patient and allowing them to guide you on the language that works for them. There can be some variability in the language that people use, particularly across age groups. If you are ever unsure of which language choices to use, politely and respectfully ask how a person would like to be referred to (see Box)^​10​.

A summary of currently accepted terminology is available in the TRANScribing resource and can further be supported by the ABC of LGBT+ Inclusive Communication from the ACCESSCare Project^​11​.

2. Be aware of the surroundings

Transgender patients sometimes look for cues about the safety of their environment before revealing information about being transgender or non-binary. Supporting cues include healthcare provider language choices; behaviour and attitudes; environmental cues, such as lanyards or posters; and opportunities for disclosure, such as inclusive patient consent forms^​12​.

Unfortunately, many clinical systems still use outdated terminology and diagnostic codes. For instance, SNOMED codes place ‘gender incongruence’ within ‘gender dysphoria’ under the parent category ‘gender identity disorder’^​13​. This is despite ‘gender incongruence’ being introduced in 2019 to depathologise transgender identity and move away from previously stigmatising diagnostic labels^​14​.

If there is a chance patients may potentially see these outdated terms and codes, it may be worth discussing this with them, explaining how systems are often slow to update and that you are committed to using the right language with them directly.

Owing to recent sociopolitical pressures, there is even greater care necessary because some seemingly non-offensive words have been weaponised against the transgender community by groups opposed to their social inclusion. For example, the term ‘biological male’ is often used to undermine a transgender woman’s gender identity^​15​.

There can also be incorrect grammatical use of transgender terms and language. ‘Transgender’ is an adjective and should follow this grammatical use. For this reason, the following examples are not appropriate: transman, as there is no space between the adjective and noun; and transgendered man, as this is a past participle of a verb. Some examples of inappropriate and appropriate alternatives can be seen in the Table below.

Similarly, there has been media furore over gendered pronouns^​16​. The reality is that pronouns are a common feature of the English language and substitute nouns in a sentence. Sometimes these pronouns are not gendered (e.g. this, that, who), and sometimes they are (e.g. he, she, they). When a person shares the pronoun that represents them, respecting this choice should be as accepted as using a person’s chosen name.

For more support in how to open the conversation with trans people about their identity and healthcare needs, see TRANScribing and the ABC of LGBT+ Inclusive Communication.

3. Create opportunities for sharing

When opening up the topic around someone’s trans status, it’s important to do so with care and compassion. This might involve giving yourself more time to get to know the patient and build the rapport necessary to facilitate a positive consultation. It is also advisable to avoid making guesses or assumptions about the person’s identity or gender. For example, instead of asking “Are you a trans woman?”, you might ask “How would you describe your gender?”. Taking this approach allows you to provide a safe opportunity for disclosure without any great knowledge of community-specific vocabulary. 

Many patients look to their healthcare providers to open up these types of conversations. By doing so, you are able to reveal yourself as a supportive person while also giving validity to the fact that gender identity can affect one’s experience of healthcare^​17​. If a person does choose to come out to you as trans — which is ultimately their choice whether to or not — it can be useful to discuss with them what the options are next for recording or sharing this information. Although this disclosure is useful for the patient’s health, there are limitations in current electronic record systems regarding where to record a person’s trans status. This issue means that an open and responsive dialogue is important to tell the patient where the information may be recorded, how it might be used and — most importantly — who might see it. 

Legal considerations

In the UK, if a patient has applied for or is in possession of a Gender Recognition Certificate (GRC), they receive certain protections under UK law under the Gender Recognition Act^​18​. A GRC allows a patient to update their legal gender on their birth certificate and will affect aspects of marital law, state benefits and pensions. A GRC protects against people working in a professional capacity revealing their transgender identity without their consent. It may be considered discrimination to ask to see a person’s GRC. The Equality Act 2010 protects transgender and non-binary people from discrimination, harassment or victimisation in employment, and as users of private and public services^​19​. The protection of non-binary people was confirmed under the Equality Act by case law^​20​.

Medicines use in patients receiving hormone therapies

Medical transition for transgender individuals may involve gender-affirming hormone therapy (GAHT), tailored to the individual’s goals and physiological response^​21​. In the UK, typical GAHT provision includes:

• For trans men, testosterone administration and possibly GnRH analogues to suppress oestrogen and progesterone. Testosterone can be administered via long- or short-acting injections or a daily topical gel. GnRH analogues are typically given every 12 weeks. Some may also use progesterone-containing medications for various reasons, for example the induction of amenorrhea^​22​;
• For trans women, oestrogen administration along with medications like GnRH analogues, alpha-reductase inhibitors and antiandrogens to suppress testosterone^​22​. 

It is crucial that clinicians understand administration methods to guide drug monitoring, screen for interactions and counsel patients effectively.

The Endocrine Society suggests regularly monitoring GAHT every 6–12 months^​23​. This monitoring should include hormone levels, prolactin, liver and kidney function, blood pressure and haemoglobin/hematocrit levels to prevent complications, such as polycythemia in trans men using testosterone. For trans women using spironolactone, potassium levels should be monitored to prevent hyperkalaemia. Bone density should also be monitored, particularly if GnRH analogues are used or in trans men using testosterone, owing to their potential impact on bone health^​23​.

Pharmacists should also be aware of potential interactions of GAHT and other medicines, including anti-epileptics, anticoagulants and cancer drugs. A table with a full list of interactions can be found here.

Pharmacists can offer guidance on lifestyle modifications — such as smoking cessation, healthy diet and exercise — to reduce the risk of venous thromboembolism (VTE) and cardiovascular risk. 

Finally, regular health screenings should be encouraged, such as bone density scans, cardiovascular health checks and cancer screening^​23​. 

Private procurement

There may be instances where a trans person is acquiring and self-administering their GAHT owing to the incredibly long waiting times for care under gender identity clinics (GIC), owing to an increase in demand for people accessing these services and NHS pressures^​24​. As a result, it is important that pharmacists and pharmacy technicians enquire about any self-administration of gender affirming care with sensitivity and respect for the individual’s identity and privacy. A way to ask could be: 

“Are you currently self-managing your gender-affirming hormones, or are you under the care of a clinician? I ask so that we can provide you with the best possible support in managing your medications.”

This question is open-ended and acknowledges the autonomy and personal nature of their healthcare decisions while indicating support and readiness to assist with their medication needs.

Gender-affirming hormone treatment and concurrent medical care

Drug dosage modulations may be required when the patient is in receipt of GAHT. This is because of physiological changes in the individual and competing action with CYP enzymes that may affect drug metabolism.

These physiological changes and drug interactions are discussed in more detail in the following sections. Given the scarcity of clinical data, clinicians often rely on data extrapolated from the general population to anticipate medication effects. Furthermore, research suggests potential sex-related differences in drug absorption, although consensus regarding trans patients is still evolving^​25​. 

Drug metabolism and interactions

Drug–drug interactions can either increase or decrease the metabolism of oestrogen and progesterone, potentially altering their levels in the body. Similarly, oestrogen and progesterone can also affect the metabolism of other drugs, leading to interactions that impact their efficacy and safety. These are often related to drug metabolism by the CYP family of enzymes. 

Senneker reviewed this topic in the context of HIV medication^​26​. In their findings, published in June 2024, the effect of feminising hormone therapy with oestradiol ± spironolactone, progesterone or cyproterone have conflicting results, suggesting that they may decrease plasma concentrations of tenofovir, a CYP metaboliser, potentially impacting its efficacy while others report no difference^​26​.

Furthermore, the use of tenofovir disoproxil fumarate/emtricitabine does not affect oestradiol and testosterone levels significantly, although a slight decrease in spironolactone exposure has been observed in trans women^​26​.

Non-nucleoside reverse transcriptase inhibitors undergo metabolism primarily via CYP3A4. Efavirenz and nevirapine have the potential to induce CYP3A4 activity, which may result in reduced concentrations of oestradiol, cyproterone, progestins, 5α-reductase inhibitors and testosterone; for this reason they should be used with caution and where possible avoided^​26​.

Ultimately, antiretrovirals remain effective when taken alongside GAHT; however, if there are changes in hormones, adjusting doses based on drug monitoring and clinical response can manage these effects effectively.

Other examples include enzyme-inducing antiepileptics such as phenytoin, phenobarbital and carbamazepine, which increase the metabolism of estradiol and progesterone, reducing their effective levels^​27​. This can impact feminising hormone therapies in transgender women, potentially necessitating higher hormone doses to achieve desired effects. Non-enzyme-inducing anti-epileptic drugs such as levetiracetam, where suitable, are preferred to avoid these interactions^​27​.

Lamotrigine, commonly used for epilepsy, is affected by oestrogen-containing therapies, requiring dose adjustments to maintain therapeutic levels^​27​.

More examples of these interactions relevant to SACT are summarised in a table available on the TRANScribing resource on the OUTpatients website. Clinicians need to remain vigilant of potential drug–drug interactions.

Drug clearance and kidney function

An essential aspect of prescribing involves calculating renal function to determine overall drug clearance. This assessment is crucial for making informed decisions about dose adjustments, determining whether medications should be discontinued and assessing the need for renal replacement therapies. 

The BNF advises use of the Cockcroft and Gault formula as the preferred method for estimating renal function or calculating drug doses^​28​. This formula incorporates the patient’s age, weight or adjusted body weight (ABW) in obese patients over 30kg/m², serum creatinine level and a constant of 1.23 for men and 1.04 for women^​28​.

Currently, there is no established guidance available on the optimal methods for assessing creatinine clearance and ABW in transgender patients undergoing hormonal therapy^​29​. Research has indicated that transgender individuals undergoing GAHT, experience physiological changes within six months of commencing hormonal therapy^​30​.

In transgender men, there is a rise in serum creatinine from an increase in muscle mass; transgender women exhibit the opposite pattern^​30​. Therefore, when calculating creatinine clearance and ABW, the appropriate constants should be used based on the duration of hormonal therapy. 

In clinical scenarios where accurate renal function assessment is crucial, methods such as 24-hour urine creatinine clearance or urinary inulin clearance may be more appropriate, although these methods are less accessible and more costly^​30​. Clinicians should also interpret renal function parameters such as creatinine and eGFR in accordance with local policies, the BNF, MicroGuide and relevant databases such as the Renal Drug Database^{​28,31,32​}.

Where possible, drug levels should be monitored and doses adjusted accordingly. This can be achieved by consulting the product literature to guide clinical decisions, always involving specialised MDT members with expertise in the specific condition being treated^​33​.

Cardiovascular health

Existing research in transgender populations, in the same way as in cisgender individuals, suggests that CVD  risk factors are affected by hormone therapy^​34​. 

Multiple studies have shown that testosterone therapy in trans men increases serum triglycerides, LDL cholesterol and decreases HDL cholesterol levels^​34​. Clinically insignificant but elevated systolic blood pressure was found in some studies, but no changes reported in others^​34​.

In trans women, studies indicate that oestrogen treatment generally leads to favourable changes in lipid profiles, including increased levels of HDL and decreased levels of LDL cholesterol^​34​. Oral oestrogen correlated with increased triglycerides levels, while transdermal oestrogen potentially lowered them^​34​.

However, increased body weight, elevated blood pressure and markers of insulin resistance owing to GAHT may mitigate the overall cardiovascular benefits of oestrogen therapy^​34​.

Currently, the long-term cardiovascular risk associated with testosterone and oestrogen therapy in transgender individuals remains uncertain owing to limited data^​34​.

GAHT can increase the risk of thromboembolism^​35​. The incidence of VTE in trans women can be increased up to 20-fold when the patient is on GAHT^​36​. Transdermal oestrogen formulations are preferred over oral formulations where risk is indicated, as they have demonstrated lower VTE rates^​37​. 

For transgender women, the concurrent use of lenalidomide and combined oestrogen and progesterone preparations is contraindicated and should be avoided with alternative treatments explored^​38​.

Pharmacist-led interventions significantly impact cardiovascular disease prevention, these include: patient education aimed at optimising medication adherence; managing blood pressure; lipid levels by promoting healthier lifestyles; including dietary modifications; regular physical activity; smoking cessation; and weight management^​39​.

Hormone receptor-positive cancers 

There may be instances where a patient is diagnosed with a hormone receptor-positive cancer. Therefore, hormonal therapy may have the potential to drive tumour growth. This is most indicated in breast cancer^​40​. In these instances, GAHT is typically paused whilst the tumour is tested for its receptor positivity. If the patient is found to have a hormone receptor positive tumour and wishes to continue GAHT, expert opinion can be sought from the UK Cancer and Transition Service^​41​.

When transgender patients in the UK need specialist information regarding the intersection of their cancer diagnosis and their gender affirming care, they are able to access the UK Cancer and Transition Service (UCATS). This is a free virtual clinic that runs as a multidisciplinary meeting (MDM) accepting referrals from clinical staff and directly from patients. Similarly, UK patients benefit from the LGBTIQ+ cancer charity OUTpatients through transgender specific information, peer support and signposting to relevant resources, which can be seen in ‘Further resources‘. 

In summary

Despite potential adverse effects, hormone therapy is generally considered acceptable for most transgender patients, with different risks associated with masculinising and feminising gender-affirming hormonal therapies. Certain factors — such as family and personal history of VTE, obesity, age and cardiovascular risk — should also be considered. Informed shared decision-making is essential for a holistic risk-benefit approach in providing optimal care.